GYNECOLOGY CASE

PRESENTATION:
“Abnormal Uterine Bleeding”

DY, EDBERT GLENN

ESCOLANO, PAULINE CATHRINE

MANDAWE, MARJORIE

RAMESH, DEEPA

SAINI, ANKESH KUMAR

VISHWAKARMA, ASHWANI KUMAR

PRESENTED TO THE DEPARTMENT OF OBSTETRICS AND

GYNECOLOGY OF VSMMC

INFORMANT: Patient
RELIABILITY: 97%
Date of Admission: October 9, 2022

GENERAL DATA

L.L, 44 years old, female, married, born on January 1, 1978, Filipino, Roman Catholic,
residing at Basak Kagudoy, Lapu-lapu City.

CHIEF COMPLAINT

came in due to abnormal vaginal bleeding

HISTORY OF PRESENT ILLNESS

3 years prior to admission, the patient noted that her menstrual cycle was
prolonged. Normally, she would have 3 to 4 days duration with no blood clots
associated however she experienced a duration of 7 days associated with blood clots.
She was able to use 3 adult diapers, fully soaked associated with undocumented fever,
paleness, dizziness and headache having a pain score of 4/10. Patient took a one
paracetamol (Saridol) 500 mg tablet as needed and offered relief to her symptoms. No
consult was done and symptoms are tolerated, assuming she was on her menopausal
stage.

Interim, patient still has experienced the same symptoms, yet no consult was
done and symptoms are tolerated.

2 years prior to admission, the patient noticed an onset of jaundice on the

extremities, sought consultation at the CLLH and was advised to get a complete blood
count. CBC revealed low hemoglobin at 4 g/dl. Patient was advised to secure 4 packs of
RBC and get admitted. However, the patient wasn’t able to secure blood due to financial
problems and no blood transfusion happened. 5 days after admission, the patient was
discharged and was prescribed multivitamins, advised to change her diet, and have a
transvaginal sonography. Patient went to her scheduled follow-up consultation after
having TVS and results showed myoma. She was appraised to get surgery and chose
VSMMC due to low cost

Interim, symptoms were tolerated. Due to financial constraints, the patient was
unable to comply right away with the surgery as directed and continued taking the
multivitamins she had been prescribed since her previous admission.

2 months prior to admission, Patient consulted in an out-patient department in

VSMMC and was advised to have a full clinical work up including transvaginal
sonography, pap smear, and biopsy. All laboratory tests were unremarkable aside from
her TVS and CBC. TVS findings showed a well-circumcised heterogenous mass
measuring 11.4 x 10.4 x 8.0 cm at the right posterior lower half of the uterus and
extending up to the cervix suggestive of an intramural myoma with submucosal and
subserosal components. Physician also stated that the mass increased in size
compared to her last TVS. CBC results also showed low hemoglobin level and was
advised to secure blood.

4 days prior to admission, the patient was able to secure blood and was admitted
in our institution

PAST MEDICAL AND SURGICAL HISTORY

Childhood illness: no known childhood illnesses

Adult Illness:

Medical: non-hypertensive, non-diabetic, no comorbidities

Surgical: removal of cyst at the index finger of the right hand (1996, Cortes
Hospital)

OB/GYN: one normal spontaneous vaginal delivery

Psychiatry: no mental illness

MENSTRUAL HISTORY

The patient had her menarche at the age of 15 years old with a 30-day regular
menstrual cycle with no history of dysmenorrhea, she claims a non-heavy flow for 3-4
days and can consume two moderately soaked pads per day.

GYNECOLOGICAL HISTORY

The patient is not using any kinds of contraceptive. She had her last menstrual
period on September 20, 2022. No pelvic surgeries.

SEXUAL HISTORY

The patient had her coitarche at the age of 19 years old with the total of one
sexual partner. The patient claims that she is not sexually active, no sexually
transmitted disease and not at risk of the said disease. The patient claims that she had
no post-coital bleeding and no sexual abuse

OBSTETRICS HISTORY
The patient is married with an OB score of G1P1 (1001). She had one child only
born on October 23, 2008 term live baby boy via normal spontaneous vaginal delivery at
Birthing Home in Lapu-Lapu with a birthweight of 2600 grams, APGAR and Ballard
score were unrecalled. Today the child is a 13 years old male currently a Grade 9
student at Bangkal National High School.

Pregnancy Pregnancy Year Gestation Sex Birthweight Present Complications

Order Outcome Completed Status Abnormalities
(week)

1 Live 2003 Term Male 2600 g Alive No

abnormalities

FAMILY HISTORY

The patient belongs to a large family with 5 siblings. Her father died because of
cerebrovascular disease and was diagnosed with hypertension while her mother is
diagnosed with hypertension and diabetes. The patient claims that her younger sister
had the same presentation of abnormal vaginal bleeding however it was resolved and
no surgeries were done.

SOCIAL AND PERSONAL HISTORY

The patient is a housewife married to a carpenter, they only had one child. She
reported that she is a highschool graduate. She claims that she does not use illicit
drugs, is not a smoker and does not drink any alcoholic drinks.

Review of Systems

GENERAL: Patient is awake, alert, coherent and responsive

SKIN: Skin is pink, no moles, no redness, no rashes, no lumps, no itching, no problem

with her hair and nails.

HEENT: The patient had no redness or pain in the eyes, no cataract, no itching and
tearing, no spots in the visual field, saw no flashing lights, no transient vision loss, no blind
spots; no hearing problems, no earaches, no tinnitus; no nasal discharges; no sinus problems,
no mouth dryness, no sore throat, no voice hoarseness, no neck stiffness, no cervical
lymphadenopathy

BREAST: No pain, no discomfort, no nipple discharges

CHEST AND LUNGS: The patient has no cough, no shortness of breath, no wheezing,
no chest tightness and no asthma

CARDIOVASCULAR: No chest pain and discomfort, patient denies palpitations

GASTROINTESTINAL: Patient has good appetite, no nausea and vomiting, no
dysphagia, no diarrhea, no abdominal pain, no liver and gallbladder problems, has regular
bowel movements

PERIPHERAL VASCULAR: No varicose veins, no leg pain and cramps, no intermittent

claudication

URINARY/GENITAL: No urinary frequency, no hematuria, no dysuria

MUSCULOSKELETAL: No muscle or joint pain, no stiffness, no gout

PSYCHIATRIC: No depression, no suicide plan and attempt

NEUROLOGIC: Memory is good and is oriented to place and time, no seizures, no

motor and sensory loss

PHYSICAL EXAMINATION

General Survey: Patient is conscious, cooperative, ambulatory and not in respiratory distress

Vital Signs:

● Temperature: 36.3 C
● Blood Pressure: 120/80 mmHg
● Heart Rate: 72 bpm
● Respiratory Rate: 18 cpm
● O2 Sat: 99% at room air

Anthropometrics:

● Height: 165 cm
● Weight: 58 kg

SKIN: Warm to touch, good skin turgor and mobility, no pallor, no jaundice no masses, no
lesions, no lumps

HEENT: Hair has normal texture. Scalp has no lesions and tenderness. Eyes have pink
palpebral conjunctiva with anicteric sclerae. Ears have no lesions, masses and tenderness. No
nasal discharges. No neck masses, trachea is in the midline

CHEST/LUNGS: No increased work of breathing, lungs clear to auscultation bilaterally, no

wheezes, rales or crackles

BREAST: Nipples are everted and symmetrical, non-tender, no discharge, no lumps

CARDIOVASCULAR: Adynamic precordium, distinct heart sounds, no murmurs

ABDOMEN: Soft, non tender, normoactive bowel sounds

GENITOURINARY
I - Parous

C -Effaced, noted prolapsing mass approximately 6 x 9 cm extending towards posterior fornix

U - 18 weeks size

A - No adnexal tenderness, no adnexal fullness

D - No discharges

EXTREMITIES: Strong peripheral pulses, CRT < 2 seconds, no edema

CNS: within normal limits

SALIENT FEATURES

Pertinent positive Pertinent negative

(+) Abnormal vaginal bleeding (-) Abdominal pain

(+) Headache (-) pelvic pain

(+) Jaundice

(+) Paleness

(+) Restlessness

ADMITTING DIAGNOSISnn

G1P1 (1001), Abnormal uterine bleeding - Leiomyoma (Intramural with

submucous and subserosal component)

S/P Cyst removal, right hand (1996, Cortes Hospital)

COVID19 negative (10/08/2022, VSMMC)

BASIS OF DIAGNOSIS

History Risk factors Physical Diagnostic/

Examination Imaging

● Vaginal ● Sibling had BPE: effaced CBC: 8.8 g/dl

bleeding the same cervix, prolapsing (09/06/2022)
● Headache presentation mass approximately TVS: well-
● Jaundice 6 x 9 cm extending circumcised
● Diagnosed towards posterior heterogenous mass
by a cervix measuring 11.4 x
physician 10.4 x 8.0 cm at the
with myoma right posterior lower
half of the uterus
and extending up to
the cervix
(08/24/2022)

DIFFERENTIAL DIAGNOSIS

Diagnosis Rule in Rule out

Leiomyoma (+) Abnormal vaginal bleeding (-) Infertility

(+) Pelvic Mass
(+) Intramural Myoma
(+) Submucosal and
Subserosal components

Adenomyosis (+) Abnormal vaginal bleeding (-) Infertility

(+) Pelvic Mass

Ovarian Tumors (+) Abnormal vaginal bleeding

(+) Pelvic Mass

Endometrial Polyps (+) Abnormal vaginal bleeding (-) Infertility

(+) Pelvic Mass

DIAGNOSTIC

Blood type : AB '' RH POSITIVE

HBsAg : Non - reactive

COMPLETE BLOOD 6 SEPTEMBER 12 OCTOBER

COUNT

WBC Count 4.14 15.44

RBC Count 2.98 4.22

Hemoglobin 88.00 126.00

Hematocrit 27.60 37.10

MCV 92.60 87.90

MCH 29.50 29.00

MCHC 31.90 34.00

RDW-CV 18.30 17.10

Platelet Count 424.00 239.00

DIFFERENTIAL COUNT

Neutrophil 47.80 89.50

Lymphocyte 38.40 38.40

Monocyte 7.50 7.50

Eosinophil 4.10 0.00

Basophil 2.20 0.30

In the September his CBC revealed a low WBC Count, low RBC Count, low
hemoglobin, low hematocrit, low MCHC and high RDW-CV. Differential count low
neutrophil and hight Lymphocyte, high Eosinophil, hight Basophil levels indicating
ongoing severe infection or inflammation.
In the October CBC revealed a high WBC count (15.44) low RBC count (4.22) high
RDW-CU (17.10). Differential count shows high neutrophil (89.50), low lymphocyte
(5.70), and low eosinophil (0.00), and normal basophil levels.

Urinalysis shows light yellow, clear, with a specific gravity of 1.005 and a pH of 5.5.
Glucose (-) and ketones (-) are absent with 0-1/ hpf RBC and 0-1/ hpf WBC, rare
squamous epithelial cells, rare bacteria and few mucus threads.

Ultrasound findings-

The uterus is anteverted with irregular contour and inhomogeneous myometrium. There
is a well-circumscribed heterogeneous mass measuring 11.4×10.4×8.0cm noted at the
right posterior lower half of the uterus and extending up to the cervix suggestive of an
intramural myima with submucosal and subserosal components.

MANAGEMENT

CASE DISCUSSION

Abnormal uterine bleeding can present in many ways from infrequent episodes, to
excessive flow or prolonged duration of menses and intermenstrual bleeding.
Alterations in the pattern or volume of blood flow of menses are among the most
common health concerns of women. The mean interval between menses is 28 days (67
days). Thus if bleeding occurs at intervals of 21 days or less or 35 days or more, it is
abnormal. The mean duration of menstrual flow is 4 days. Few women with normal
menses bleed more than 7 days, so bleeding for longer than 7 days is considered to be
abnormally prolonged. It is useful to document the duration and frequency of menstrual
flow with the use of menstrual diary cards; however, it is difficult to determine the
amount of menstrual blood loss (MBL) by subjective means. Although mortality and
serious complications of AUB are uncommon, their effect on health-related quality of life
is significant.

The International Federation of Gynecology and Obstetrics (FIGO) in 2011 subdivided

causes of AUB into nine main categories, which are arranged according to the acronym
PALM-COEIN: Polyp, Adenomyosis, Leiomyoma, Malignancy + Hyperplasia,
Coagulation, Ovulatory dysfunction, Endometrial, Iatrogenic, and not yet classified. The
causes that constitute the first group (PALM) are structural or histologic and are
diagnosed through imaging or biopsy. Those that compose the second group (COEIN)
are nonstructural

When a woman presents with a complaint of abnormal bleeding, it is essential to take a

thorough history regarding the frequency, duration, and amount of bleeding, as well as
to inquire whether and when the menstrual pattern changed
EPIDEMIOLOGY

INCIDENCE

ETIOLOGY

PATHOPHYSIOLOGY

MANAGEMENT